The Argument For MAT

The position of the Department of Public Health in Massachusetts is that Medication Assisted Treatment (MAT: Methadone, Buprenorphine, Naltrexone), is not Harm Reduction (eg. safe injection equipment, condoms for HIV). While its benefits may indeed not be limited to harm reduction, it is undeniable that MAT clearly reduces many potential injuries associated with opioid addiction. It does so in 4 ways:

1) It immediately eliminates any withdrawal from opioids. This point cannot be overstated. When addicted to opioids, the individual is in a constant race against time. If the person doesn’t find and take in more opioids, within 24 hours or so he will start a slide into incredibly painful and uncomfortable withdrawals that can last many days. As the quantity of opioids increases – which it necessarily does due to tolerance and the strength of the opioids on the streets (especially fentanyl) – so does the agony of the withdrawals. This makes it very hard to successfully wean oneself off the opioids. The brain is constantly screaming for some opioids to end the pain of withdrawal. Imagine this battle in your head stretching out for days, even weeks. It is incredibly hard to stay with the discomfort. At one point in the film The Good Thief, Nick Nolte’s character has someone handcuff him to the bed so that he won’t give in during these agonizing withdrawals.

An individual wishing to come off opioids can check him or herself into a detoxification program, but by definition detoxification units are designed and paid for by insurance to withdraw a person from any drug only until the medical dangers of withdrawal have passed. The length of stay is not long enough to protect someone from the harmless yet longer-lasting ill effects of the withdrawal, such as what I call “restless body syndrome” or insomnia. This abbreviated stay thereby increases the chances that the person will give up and use.

2) Methadone and Buprenorphine fill the receptor sites on the neurons the illicit opioids previously filled, and so reduces much of the craving for the opioid that accompanies that slide into withdrawal. Naltrexone – Vivitrol is the name of the monthly shot – does not. It is only an opioid blocker.

3) There are many well-designed studies that show that Methadone and Buprenorphine reduce by roughly half all opioid overdose deaths. Here are two meta-analyses (meta = analysis of multiple studies)  https://doi.org/10.1136/bmj.j1550; Cochrane Database Syst Rev.

4) There is also good evidence that Methadone and Buprenorphine cut the number of relapses to opioids in half, when the dosage is right. For Buprenorphine, the study authors note that Buprenorphine must be given at doses 16mg or greater for relapse rates to drop. https://www.ncbi.nlm.nih.gov/pubmed/24500948

Given the high overdose death rates we are seeing across this country, the strength of the street drugs, and the weight of the above evidence – regardless of whether you are a novice or have been using opiates for 10 years – the first thing I always recommend to families is to get your Loved One on MAT as a first line of defense.

But here’s the problem. I see it in my own work with jails, in the recent literature, and the direction policy is headed. The emphasis on a carefully designed, integrated treatment plan is dwindling. Efforts made to implement such plans are less robust.

MAT was designed as part of a three-legged stool: medication, psychosocial support and mutual aid. The full spelling of MAT in fact is: Medication-Assisted Treatment, that is, medication in support of substance use disorder treatment. You have but to look at the report of a SAMHSA/NIH sponsored Buprenorphine summit in 2014 for evidence that two of the three legs are dropping away. In over 80 pages, the words therapy/counseling/self-help appear just 8 times.

One reason this is happening is due to the rather surprising finding that adjunctive therapy combined with the medication doesn’t seem to improve outcomes. https://www.asam.org/docs/default-source/advocacy/mat-with-buprenorphine-summarizing-the-evidence.pd. However the authors note this is an area in need of further research on this, particularly around which psychosocial interventions seem to be most effective within various populations.

A white paper by the Hazelden/Betty Ford Organization argues that until MAT clients are carefully matched to quality, need-specific, evidence-based psychotherapies, we are doing opioid use disordered clients serious harm. We are not providing clients with a carefully tailored integrated plan that will address the long-term needs of living life free of illicit opioids (never mind the other drugs of abuse that so many individuals struggle with and sometimes turn to when opioids are off the table).

To address the question recently posted on this blog of whether someone needs to be put on MAT for a lifetime: The American Society of Addiction Medicine recently came out in favor of medication for life. The analogy you often hear equates MAT for addiction with insulin for Diabetes. For some this may be true. There are those who physically need or want to stay on the drug. There are those who don’t want to make any lifestyle changes and prefer to rely on the medication. And then there are others who, after getting stable with the help of the medication, want a fighting chance to eventually come off the medication. I follow the blog of a MAT prescriber whose common sense and care for her patients helps them taper off when they are ready. It is indeed possible to live a good life without MAT, but I believe success largely depends on the willingness to work a program of recovery.

The same can be said of other prescription medications for various health conditions. Expecting to stay on a medication for life goes along with a certain perspective about one’s health. People approach this prospect differently based on a variety of factors, again, having to do with what lifestyle changes they may or may not be willing to explore to address their health condition or conditions. Wherever one falls within this spectrum, quality of life remains a relevant consideration – for any medication. For those who remain on MAT for life, the quality of life that allows them should not be minimized in this discussion.

Side-effects have not been fully studied at this point. In MAT with Buprenorphine: Assessing the Evidence, however, a number of findings are discussed, including the safety profile of buprenorphine especially in relation to cardiac electro-physiology. These findings were positive (Martin et al. 2011) The authors also note that buprenorphine “has fewer drug interactions than methadone, especially with HIV medications.” And the article cites various maternal and neonatal studies on buprenorphine, showing promising numbers related to neonatal abstinence syndrome and infant development. (Jones et al., 2012)

While long-term side effects remain to be fully studied, based on the evidence that is immediately available, there are many reasons to consider MAT as a first line of defense. Given the scale of the opioid epidemic, and the potency of what is on the street, those afflicted stand a fighting chance with the addition of MAT to their arsenal. Emphasis is on the use of MAT as it is intended – within the context of that three-legged stool: medication, psychosocial support and mutual aid.

One of our members recently wrote in about her work managing two sober homes. She reports that, when taken as directed, Suboxone has about a 70% success rate in this setting. This is a very good outcome. I have just started crunching the numbers for one of my jail grants, and "success," defined as 4 weeks of urine tests that are negative for illicit opiates, is just under 30%. Out of 125 inmates who leave jail, and who are either started on MAT while in jail and/ or case-managed to a community MAT program, 91 go to their first MAT appointment, and 27 are clear of opiates in month 2 (so just under 30% of the 91). This is with ongoing case management and bus tokens for transport. They are not clear of other drugs necessarily. In comparing our outcomes, one could argue that sober housing is boosting outcomes by 40%!!!  Folks in those sober housing programs may not be so different than inmates leaving a county jail. In Springfield, 1  in 7 pass through the local jail every year.

Neither the sober houses mentioned nor the jail grant is a rigorously designed randomized clinical study but the differences are suggestive of how important safe, structured housing may be to addressing opioid addiction.

If only we were asking questions like this in the research: how much does safe sober housing increase the success of suboxone?

As a treatment system we are not actively and intensively case-managing people into quality psychosocial therapies and mutual supports. Instead the field is dividing between “Drug-free” and MAT, as though being abstinent of illicit drugs and on MAT is not “drug free.” Followers of the above-mentioned blog on tapering note that we should be celebrating the sobriety of anyone who is able to stay off drugs in the long term, not discounting the success of those who are doing so with the assistance of medications.

If this blog does nothing else, I hope it sheds a light on the sheer complexity of addiction and the need to create treatment plans tailored to the individual. Such plans would need to include medications (both for addiction and mental illness), evidence-supported psychosocial therapies, connection with a community of concern, and help meeting the basic needs of life: through safe housing, finding and maintaining work that pays a living wage, help with children, transportation, and the family training we provide at Allies in Recovery.